Patient is 88 year old female admitted to the hospital with a two day history of
ID: 243825 • Letter: P
Question
Patient is 88 year old female admitted to the hospital with a two day history of feeling SOB, lightheaded, dizzy, and chest pain. The patient lives in a single family house, and the bedroom and bathroom are located on the second floor. The patient was brought to the ED by the family. The nurse starts to perform the nursing assessment and finds that the patient is only oriented to person. The patient does not report any pain. The vital signs and the laboratory results are recorded as the following:
Temp. 38.1 pulse 98 resp. 32 Blood pressure 122/80 SpO2 with RA at Pulse Ox 89% , weight at 120 pounds (54.54 Kilograms), height 5.4
Na 148
Cl 96
Potassium 3.5
Bicarb 39
BUN 50
Creat 1.78
Glucose 124
Hgb 6.6
Hct 21.5
WBC 24.9
Platelets 145,000
Albumin 3.5
ROS:
Negative
PMH: CAD, CKD, HTN, COPD
PSH: Bilateral knee replacement
Social hx: lives alone, drinks one glass of wine once a day, denies smoking and drug abuse
Allergies:
NKDA
Medications at home: Lisinopril 40 mg once a day, ASA 81 mg once a day, Lasix 40 mg once a day, Advair one puff every 12 hours
Physical Exam:
Awake, confused to time and place, oriented to self
Mucous membranes dry, tongue pink
HEENT: AT/NC, PERRLA, neck supple, no JVD
CV: RRR, Normal S1 S2, no m/r/c heard
Lungs: Breath sounds vesicular with crackles in the posterior bases
ABD: distended with faint bowel sounds, tender to touch
Extremities: upper and lower extremities with strength at 3/5 for all four extremities
Has 3+ edema in lower legs bilaterally
Skin: small open redden area on left thigh
Diagnostic Exam:
ECG: Normal
2D echocardiogram: LV function at 20%
Answer the following questions:
Identify the abnormal lab tests.
Identify two nursing diagnosis for this patient.
Identify two nursing intervention for each nursing diagnosis with rationale.
Identify one short term goal for each nursing diagnosis.
Identify one outcome for each nursing diagnosis.
List the medications for the patient.
List the diagnosis test ordered for the patient and the results.
Explanation / Answer
Abnormal lab test:
Nursing Diagnosis:
Nursing Interventions:
Short term Goal
Medication
Diagnosis test